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ENHANCED MOOD & ENERGY DOCTOR SUPPORT FAT & WEIGHT LOSS MUSCLE GAIN & STRENGTH MUSCLE & INJURY RECOVERY VITALITY
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Registration & Assessment

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New Client Registration Form

All fields marked with * are required and must be filled

Name*

First Middle Last

Gender*

Male
Female

Date of Birth*

Weight (kg)*

Height (cm)*

Phone Number*

Email*

Enter Email Confirm Email

Address*

Street Address

Suburb/City State / Province / Region

ZIP / Postal Code

Country

medicare_card

Medicare Number Details* Ensure medicare details are correct to reduce risk of account being declined

Reference Number*

Expiry Date*

Are you an athlete in a sport that subscribes to the WADA World Anti-Doping Code?*

Yes
No

What products are you interested in? (Tick all that apply)*

Anti-ageing
Muscle building
Fat loss/weight loss
Safe enhanced tanning
Injury repair
Increased libido
Hair loss solutions
Increased energy
Improved mood

What are some of your goals?

What do you expect to achieve?

Do you have any pathology test in the last 12 months? *

Yes
No

NOTE: By submitting your test result or taking a test with one of of our pathologies it will help us to maximise your potential to achieve your goals and improve your health an fitness.

Do you have any allergies to medications?*

Yes
No

Do you smoke?*

Yes
No

Do you experience any of the following? *

Profuse sweating at night
No interest in eating / Loss of appetite
Unexplained weight loss or weight gain
Any abnormal growth or lumps (including new beauty spots)
Fevers / Flu like symptoms
Exhaustion / fatigue

Have you used peptides before?*

Yes
No

Have you ever been admitted to hospital in your life past or recent?*

Yes
No

Have you ever been admitted to hospital in your life past or recent?*

Yes
No

If Yes, Details of Admission?*

Have you had any form of cancer in the past?*

Yes
No

Thyroid disease*

Yes
No

heart disease*

Yes
No

Untreated / Uncontrolled diabetes mellitus*

Yes
No

hypertension*

Yes
No

Do you have any current medical or surgical problems?*

Yes
No

Are you currently pregnant or breastfeeding?*

Yes
No

Create Username*

Password* Enter Password Confirm Password* Confirm Password

Please complete all the required fields. (Highlighted in red)

Products

All
Anti-Aging & Vitality
Build and Repair Muscle
Enhanced Libido
Increasing Energy
Lean Muscle Gain & Strength
Men’s Bundles
Muscle Injury & Recovery
New Products
Weight & Fat Loss
Womens Bundles

ABOUT US

Our peptide supplements are prescribed by our anti-ageing professionals and compounded for your convenience in one of our Australian pharmacies.

FOLLOW US

Email:

[email protected]

Postal Address:

101/245 St Kilda Road, St Kilda, Melbourne, 3182

©Copyright 2019 - 2021. All Right Reserved

In order to serve you better, we have made a few updates

New registrations are now required to provide a recent blood report. If you haven't done a test recently, we can refer you to one of our pathologies
Shipping service has been updated from Australia Post to a fast courier service.